FAI into death of transgender prisoner finds Scottish Prison Service unlawfully segregated her, failed to assess risk

About this case:

• Citation:
  [2025] FAI 42
• Judgment:
  External link
• Court:
  Sheriff Court
• Judge:
  Sheriff Pino di Emidio

Sarah Jane Riley died at some time between 17:15 on 11 January 2019 and 08:09 on 12 January 2019 at HM Prison Perth, where she was imprisoned subject to an Order for Lifelong Restriction. As she died in custody, a mandatory inquiry was held under the Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016.

The inquiry was conducted by Sheriff Pino Di Emidio at Falkirk Sheriff Court, with the Crown represented by I Davie, advocate depute, and the Scottish Prison Service by P Reid KC. Other represented parties included the Scottish ministers, Tayside Health Board, and the Scottish Prison Officers Association.

Kept for 18 days

On first arrival at Perth Prison in December 2007, the deceased was assessed as suicidal. She was given an OLR at a sentencing diet of December 2008 with a punishment part of two years and 8 months. Around February 2015, she declared her wish to live as a woman and began living as such while in adult male open conditions. In June 2016, when the deceased was 26 years old, a psychological assessment concluded that she met the diagnostic criteria for several personality disorders, and later a diagnosis of gender dysphoria.

In 2018, after an unsuccessful period of transfer to the female estate, the deceased was released on licence to the Anchor House facility in Perth, and during her time there she regularly stated that she would end her life if she was recalled to prison. She was recalled to Perth Prison following a breach of licence in November 2018.

Although she was assessed under the Talk To Me programme as “no apparent risk”, she presented with self-harm wounds and was kept in solitary confinement in the Separation and Reintegration Unit without legal authorisation. None of the staff in the SRU had any knowledge of the impact the deceased’s OLR and the recall to custody had on her. She was kept in the SRU without legal authorisation for a period of about 18 days from 6 to 24 November 2018.

While it was noted that a mental health assessment was required for the deceased, this was never completed and attempts to transfer her to other prisons were unsuccessful. On 11 January 2019, the day of her death, the deceased was informed that she had been refused parole and would remain in closed prison conditions for at least 12 more months. It was noted that the deceased was a complex prisoner and the failures that led to her recall would have prompted feelings of rejection and abandonment.

It was found that, as an OLR prisoner, the deceased was subject to extensive risk management processes, however the updates to her Risk Management Protocol following her recall were not completed before her death. It was also noted that the RMP was focused on the risk prisoners posed to other people, with no consideration of risk to themselves.

Failures all avoidable

In his determination, Sheriff Di Emidio said of the effect of the deceased’s prolonged period in solitary confinement: “The problem of suicide risk is complex. SPS sought to achieve a balance between adequate surveillance and the imposition of such an oppressive regime that it causes more harm to those it seeks to protect. The period Sarah would spend in the SRU was prolonged without an end in sight so long as there was no realistic prospect of transfer. This was not due to any misconduct by Sarah. No mechanism existed to trigger a more intense focus on Sarah that had regard to her diagnosis, her status as an OLR prisoner and her status as a [transgender] prisoner.”

He continued: “To borrow the very apt phrase used by the advocate depute, Sarah was kept in a holding pattern once it was decided she was to be transferred to another prison. The problem with that was that there was a serious failure of support and engagement while a prolonged and unfocused transfer process achieved very little, if anything at all.”

Noting that Perth Prison was not equipped to deal with the sudden arrival of a prisoner with the deceased’s complex needs, Sheriff Di Emidio said: “The inappropriate use of segregation for a prolonged period in circumstances where the prisoner had not acted in a manner that merited removal from association. Once the prison authorities decided that Sarah had to be transferred elsewhere in line with the TSG policy, progress was slow. Meanwhile Sarah had to be accommodated within the SRU. This was not well managed.”

He added: “The defective processes described in this determination regarding delays in arranging case conferences, persistent failures to attend case conferences when they took place, delays in mental health assessment, failures to operate Rule 95 [of the 2011 Prisons Rules, on removal from association] at the correct time and the failure to appoint a personal officer to Sarah were all avoidable.”

Sheriff Di Emidio concluded: “It is a matter of regret that serious problems arose because substantial numbers of documents relating to Sarah were not produced when they should have been. Crown counsel thought there was sufficient cause for concern that a police investigation was instructed into the failure to produce prison records. Although it is not strictly a statutory recommendation, I think it is appropriate to recommend that SPS should put in place a system for ensuring that steps are taken forthwith to secure all records, in whichever medium they may be held, relating to a prisoner who has died while within its estate.”

The sheriff therefore made 12 recommendations for improvements to the SPS’ system of working, including the establishment of a system to allow for assessment of OLR prisoners’ risk to themselves, prompt consideration of whether a recalled prisoner ought to be transferred, and review of decisions to remove OLR or transgender prisoners from association.